NRNP 6635: Psychopathology and Diagnostic Reasoning Comprehensive Psychiatric Evaluation: Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD

NRNP 6635: Psychopathology and Diagnostic Reasoning Comprehensive Psychiatric Evaluation: Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD

Subjective:

CC (chief complaint): The patient is a Caucasian male who admits to having a body image preoccupation when he enters the clinic. He believes that because he constantly feels out of shape, no one genuinely finds him attractive. He adds that for a considerable amount of time, he has been plagued with intense, persistent compulsive ideas of altering his body image at all costs. This has caused him to visit various gymnasiums in an effort to transform his body image to the ideal he dreams about. But because he has not actually achieved this goal, it keeps on worrying huim and he cannot take the thought off his mind.

HPI: The client is a 35-year-old Caucasian male who presents with the aforementioned problems. His daily life has been so greatly impacted by the fixation and compulsion that he now spends nearly every day in the gym. He has developed social, interpersonal, professional, and even self-care dysfunctions. He just considers going to the gym to alter his appearance, which is not occurring. He claims that these symptoms started in his late 20s even though he had no prior history of them. They remained there until a recent suggestion to seek mental health assistance from a family member. The signs are persistent and challenging to disregard. The manifestations are made worse by being with other people, while they are somewhat improved by isolation. He gives the obsession and compulsion a 7 out of 10 severity rating.

Past Psychiatric History:

• General Statement: The client cannot recall ever having any mental illnesses in the past.
• Caregivers (if applicable): He still does not need carers despite his self-aware disorder.
• Hospitalizations: He does not have a history of hospitalization.
• Medication trials: He denies ever being put on any medications for a mental health problem.
• Psychotherapy or Previous Psychiatric Diagnosis: The absence of a previous psychiatric diagnosis means that he has never been on any psychotherapy intervention.

Substance Current Use and History: The client claims that for the previous 15 years, he had been drinking sometimes, but recently, on the suggestion of his primary care physician, he began cutting back. He denies ever having smoked cigarettes, although he acknowledges using cannabis for a while before quitting a year ago when the business he worked for relocated. He denies ever misusing prescription drugs or utilizing illegal substances.

Family Psychiatric/Substance Use History: Neither his mother nor his father smoked tobacco or drank etoh. However, he has two brothers who are smokers. They are all non-drinkers. As far as he remembers, and the much he has been told, no one in his family has ever had a mental diagnosis or therapy.

Psychosocial History: He used to be very outgoing and frequently went out for drinks with his buddies. These days, he only infrequently still does this since he lacks the time. He spends the most of his time lifting weights in the gym to gain muscle. He makes every effort to live a healthy lifestyle, eating lots of fruits and vegetables. In order to maintain his health, he stays away from refined foods with lots of fat and overly sweetened drinks like soda. He enjoys watching movies, dancing, going to the gym, and jogging. He was a worker at the neighborhood district court until lately, when he was let go for running away from his work. He no longer works and now relies on his parents and siblings for support; he does not even consider looking for another employment because doing so would conflict with his exercise routine.

Medical History:

• Current Medications: He is not presently on any medications that he knows of.
• Allergies: He denies having any allergies that he is aware of at the moment.
• Reproductive Hx: He identifies as a heterosexual man who was previously married but recently got a divorce due to his fixation and compulsion with body image. He has two children with the wife, and the mother currently has custody of them.

ROS:

• GENERAL: He disputes any symptoms of lethargy, malaise, headache, fever, or chills.
• HEENT: Light-sensitivity, double vision, ringing in the ear, otorrhea, rhinorrhea, gum bleeding, and a sore throat are not present in him. Moreover, he refutes dysphagia.
• SKIN: Negative for itchin
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